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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> Public Health Services. / �/'� <br /> Job Adtiresa / 5` / id-� rr te"'1 r ry 4" City Lot Size/Acreage ri�sY AC-e-cs <br /> Owner's Name _ Address ZPhone <br /> csnlraef Address icense No.AW4L h�Pho <br /> PE Of WIELL/PUMP: NEW WELL 0 bo-e WELL REPLACEMENT 11 DESTRUCTION O Out of service well <br /> PU ! O SYSTEM REPAIR 0 OTHER dM <br /> Monitoring Yell <br /> a orb +A <br /> DISTANCE TO NEAREST: SE tANK�W_ S gg LI E ,IDDM DISSq A D.r000_ PROP. LIN! <br /> FOUNDATION .fwd ATE WELL OT 1 PITS/SUMPS ,l�rj <br /> _ a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ON <br /> Ll Industrial O Open Bottom O Manteca Din. of Well Excavatt* n� Dia. of Well Casing <br /> t"1 Domestic/Private Cl Gravel Pack C1 Tracy Type of Casing-X- - Specifications <br /> I.1 Public OW Other n Delta Depth of Grout Seal -�— Typo of Grout <br /> 1 I Irrigation ',-�Approx. Depth I I Eastern Surface Soul Installed by ,fir w- <br /> Repah Work Done 0 Type of Pump H.P. State Wo one r <br /> Well Destruction O WON Dismeter ;wed. ea&linS Material i Depth <br /> Depth 6W Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I 1 (No seplic system permitted if pttbk sewer Is <br /> available within 200 feet.) <br /> Installation will Servs: Residence_ Commercial_ Other <br /> Number of Nving units: Number of bedrooms <br /> Character of W to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. b Length of fines Total length/size <br /> FILTER BED 1:1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby cortify that 1 haus prepared this application and that the work will be done in accordance with Son Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin county <br /> Homo otw+lor or Neonsed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ Sny pis W in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractN►g signature <br /> cerlfts fila bWwing:"1 certify that in the performance of the work for which this permit is issued,i shall employ persons subject to workman's componss- <br /> tion 1161"of CaNiornla." <br /> The sppNcant 111111111110 call for ON required Inspections. Complete drawing on reverse side. PID <br /> - n <br /> Signed X AW Title: 4A4 a I a <br /> FOR DEPARTMENT USE ONLY <br /> Applicstion AecOpted by bete Z Area <br /> Pit or Grout inspection by Date Frost Inspection by AQ Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK I RECEIVED SV DATE FERM17'NO. <br /> TWO C'� q CASH ,n <br /> . <br /> IN 3-14 taEV.Iola .J S C� 1 t O O ��.O'L� O r ' �� 7 Z00532 1 <br />